Originally published in Massage Bodywork magazine.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.

Whether you are a sole practitioner working in your home or office, working for or owning a spa, providing service in a chiropractic or physical therapy office, focusing on seated massage, specializing in outcalls, or a combination of several of these venues, safety is an often overlooked feature of our practices and businesses. Furthermore, there is a greater possibility today of legal action due to unsafe conditions, both in the form of lawsuits and possible fines. As therapists, we strive to be safe, but we've not had formal training in "safety." We often just use good common sense, rely on good luck, and strive to be safe in ways we know how.

For most people, safety is simply not having an accident. It is following safety rules we have either been taught (look both ways before crossing the street) or learned through professional experience (wash your hands in between clients). This limited understanding of safety has numerous shortcomings and eventually leads to a breakdown of safety -- an accident. Acting safely is associated with identifying and controlling hazards and risks, but this simple formula overlooks the human factors of behavior and inexperience.

In behavior-based safety, we understand that consequences determine behavior. Safety professionals and behavioral scientists throughout the world have come to realize safety must become part of an individual's and business's human values -- values which outrank priorities.1 People are the most important part of any event, be it a massage session or a casual lunch date. Once you value safety, it becomes part of your personal and business behavior. While behavior is an extremely complicated subject, one can safely say that behavior is often a direct function of consequences.2 Therefore, one's behavior is based on what one believes the consequence(s) will be.

"OK, makes sense to me. So now I will 'think' more about safety. However, where are the checklists?" While checklists are a useful safety tool, no single checklist can cover every area, field, office, spa or activity. We instead must first understand some of the basic concepts of safety. An explanation of common safety terms allows us to easily incorporate proven behavior-based safety practices into our practice and life. Here are a few from the National Safety Council:

Accident -- An unplanned, undesired event, not necessarily injurious or damaging, which may disrupt the completion of an activity. 
Hazard -- Any condition in the workplace [or any place people are located] that, by itself or interacting with other variables, could cause death, injuries, property damage or other losses.
Hazard Control -- Developing a program to recognize, evaluate and eliminate (or at least minimize) the destructive effects of hazards in the workplace.
Loss Control -- The prevention of occupation injuries, illnesses and accidental damage to the business's property. Losses from hazards include production losses, injury to employees, property damage, public liability and business interruptions.3

When I first learned these explanations of accident, hazard, hazard control and loss control during Supervisor Safety Training, I didn't know whether to giggle, roll my eyes complacently, or begin daydreaming. To me, the explanations seemed to be a mix of common sense, irony and potential tools. As the class progressed, I quickly realized how these explanations of common safety terms guided safety behavior. For instance, an accident was not just an "oops," -- it included the concept of a near accident (also called a near miss) or what we commonly call "lucky." Statistics show that roughly 75% of industrial injuries are forecast by "near accidents."4 By studying the conditions that lead to near accidents, we can prevent accidents.

However, many of us feel that safety is universal, based solely on our experience and common sense. Psychologists and safety professionals have learned that common sense is very subjective since it is based on each individual's experiences and their perceptions of those experiences.5 So when someone engages in behavior which puts them at risk for an accident, that person is acting unsafely. Risk is the possibility of loss or injury. Real risks are determined by the magnitude of loss if a mishap occurs, whereas perceived risks are based on our experiences and perceptions. We often engage in at-risk behavior because our perceptions or, more accurately, misconceptions are incorrect. This is why the idea of a "Safety Cop" often fails. No one can be supervised 100% of the time; a simple lapse in concentration can be a precursor to either a near miss or an accident. Traditionally, we underestimate risk and overestimate our own skills.6 Since we feel the consequence of an act will not lead to an accident, we tend to behave unsafely. The two most common groups of people who experience accidents are the inexperienced and the very experienced -- the inexperienced because they lack knowledge and skill; the very experienced because of complacency.

As massage therapists, we understand how each individual perceives an event as deeply personal and may even hold it in the body. Everyone's perception is defined by the information received. For each of us, that information is interpreted for its relevance, determined if it is worth remembering or responding to, and, if called for, a response is planned and executed.7 Because each one of us walks our own path, our experiences and perceptions will always be unique.

Therefore, behavior-based safety must be a group effort. By having the wealth of many different experiences and perceptions, we can better assess our work environment. When you make the decision to help someone, you are actively caring.8 Your act of deliberately getting involved both helps your personal growth and positively influences another person. Safety then becomes part of our behavior and our values.


Putting It To Work
So how does this discussion of behavior-based safety impact your practice, business, spa, etc.? Legally and professionally, directly or indirectly, everyone is required to act safely (read your insurance policies, legislation and ethical codes). Safety is called for by your client, self, staff and visitors. Tools and machinery have safety devices, such as the low water alert on a hydrocollator, or the directions that arrive with a photocopy machine. A safety program will differ for each entity because each business has its own culture, values and individually unique staff. My points below are simply to provoke thought and aid with a safety assessment of your work area. It is by no means a complete list. The purpose of the following compilation is to give an introduction and insight into the process of behavior-based safety. For more detailed information, contact the American Society of Safety Engineers at 847/699-2929 (www.asse.org), Board of Certified Safety Professionals at 217/359-9263 (www.bcsp.com) or the World Safety Association at 660/747-3132 (www.worldsafety.org). 


Practices in a home, small office or large group (i.e. chiropractor) 
- Make sure your massage table is in good working order (braces/cables correct, legs tight, height correct for you, anti-fatigue mats, secured electrical cords). Check your table daily.
- Teach clients how to properly get on and off the massage table.
- Eliminate slipping, tripping or fall hazards (electrical cords, rugs, hangers or "Silent Butler" for client's clothes, wiping lotion off clients feet).
- Arrange room layout with straight lines to walk around so as not to challenge a client who may be unsteady on their feet, using walking aids or a wheelchair. Have no tears or holes in rugs and practice good, general housekeeping.
- Have a fire extinguisher (especially if candles, incense or other types of open flame may be used during a session; halogen lamps also generate extreme heat).
- Have a Ground Fault Interrupter (GFI) circuit for any appliance that uses water (i.e., hydrocollator, waterfall, coffee maker, hot tubs, saunas).
- Make sure all electric fans have fan guards securely attached.
- Implement safe storage of items (shelves not overloaded, weight in file cabinet drawers equally distributed, heavy shelves and file cabinets secured to the wall, bookcases secure from tipping, items not stacked to the ceiling so water sprinklers can operate correctly).
- Use plastic cups for client's water (instead of breakable glass).
- Have emergency evacuation items on hand, including flashlight, robe, emergency phone numbers, route(s), designated assembly area for emergency evacuations.
- Know the rules and regulations of biohazard and blood-bourne pathogen protection including latex gloves, barrier creams, antibacterial soap, antiseptic cleansers for massage table/chair, tissues, waste receptacle.
- Know the precautions and hazards of antiseptics and cleansers.
- Establish a convenient location (i.e., tabletop) for client's prostheses.
- Post-emergency phone numbers for client(s) and self.
- Read business/liability insurance policy.


Waiting or Reception Areas
- Train new/temporary employees with safe work practices.
- Have a first aid kit stocked with current supplies.
- Know the location of the building's fire alarms/pulls, fire extinguishers, emergency evacuation route(s), unobstructed fire doors; police, EMT and fire phone numbers (not everyone is on the 911 system); designated assembly area for emergency evacuations, EXIT lights working.
- Have sturdy, non-tip chairs; furniture, decorations and other furnishings in good condition, good general housekeeping, excess paper and trash removed.
- Rugs must be free of tears and holes.
- Guard rails must be secure and sturdy.
- Lay out office with straight lines to walk around so as not to challenge a client who may be unsteady on their feet, using walking aids or a wheelchair; aisles free of obstructions; machines not overheated. 
- Eliminate standing water to prevent slips (especially around the coffee maker, water cooler, entryway and pools).
- Ensure every electrical panel has 36 inches of clearance around it.
- Implement safe storage of items (nothing heavy on shelf which could fall during earthquake, weight in file cabinet drawers equally distributed, items not stacked to the ceiling so water sprinklers can operate correctly, computers on sturdy, ergonomic station).
- Place no items on steps/ramps (even temporarily); stair treads must be in good condition; ramps must have non-slip surfaces.
- Identify and correct "blind corners" with windows in doors, mirrors, etc.
- Know the precautions and hazards of chemicals used in the office (i.e., photocopy machine toner and fixative, disinfectants, cleansers, janitorial supplies); have Material Safety Data Sheets (MSDS) available for all chemicals.
- Establish a safety plan.
- Have a camera with flash to document near accidents or accidents.


Chair Massage
- Have chair in safe working order; have supplies to sanitize chair in between clients.
- Have adequate room for therapist to work using proper body mechanics.
- Screen clients (either verbally or with a questionnaire); determine any contraindications.
- Provide immediate care for clients who are light-headed, dizzy or fainting.
- Utilize an ergonomic transport of your chair.


Outcalls
- Implement a careful screening program of clients.
- Utilize an ergonomic method of transport for table, chair and supplies.
- Implement a check-in/check-out method.
- Have police/law enforcement phone numbers on hand.
- Always keep car keys on your body.
- Have a large enough area to work with proper body mechanics.
Personal Safety
- Have current Red Cross CPR/First Aid training.
- Implement careful client screening.
- Keep client's charts current with changes in medical history.
- Know proper verbal skills to diffuse situations -- practice.
- Use seat belts and child carrier seats.
- Prevent overuse injuries.

Sandra Gill, NCTMB, MA, operates her practice -- The Right Touch -- in Thornton, Colo. She retrained professionally as a massage therapist at the Boulder College of Massage Therapy after being downsized from Rocky Flats Environmental Technology Site (RFETS). She taught Health and Safety training for seven years, as well as completing National Council Safety Supervisor, Total Safety Culture and Dupont Managing Safety programs. Gill is also a licensed social studies teacher and has her master's in secondary education. She may be contacted at Outspoken1@aol.com; http://members.aol. The author wishes to thank Joann Jackson-Bass, Certified Safety Professional (CSP), Certified Safety Manager (CSM) of the World Safety Organization. She may be contacted at Kaiser-Hill, 303/966-3462.

References
1. Kelley, F. Richard, "Worker Psychology and Safety Attitudes," Professional Safety, (July 1996):15.
2. Gregory, Earl D., "Building an Environment That Promotes Safe Behavior," Professional Safety, (October 1996):23.
3. Laing, Patricia M., ed., Supervisor's Safety Manual, 9th ed., (National Safety Council, 1997): 3-4.
4. Ibid.
5. Geller, E. Scott, The Psychology of Safety, (Radnor: Chilton, 1996): 9.
6. Ibid, 59.
7. Ibid, 52.
8. Ibid, xi, 235. 

Resources
Krause, Thomas R., Employee-Driven Systems for Safe Behavior, (New York: Reinhold, 1995).
Krause, Thomas R., Hidley, John H. , and Hodson, Stanley J. , The Behavior-Based Safety Process (New York: Reinhold, 1990).


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Common Techniques


Longtitudinal Gliding

Longtitudinal gliding is a basic but effective massage technique administered in the direction of the blood flow. It aids the fluid dispersion from the injury site, and thus helps reduce inflammation and swelling. It is also very useful in relaxing tight muscles.

Kneading

Kneading can be performed in different ways and is described by the part of a hand used to accomplish the massage, eg thumb kneading and palm kneading. The pressure used must vary according to the purpose of the massage and the bulk of the tissues under treatment. The rhythm and rate of the movement are equally important as the pressure is applied intermittently.

Myofascial Releases

Myofascial release is manual technique for stretching the fascia with the aim to balance the body. Fascia is located between the skin and the underlying structure of muscle and bone, it is a seamless web of connective tissue that covers and connects the muscles, organs, and skeletal structures in our body. Injuries, stress, trauma, and poor posture can cause restriction to fascia, and the goal of myofascial release is to release fascia restriction and restore its tissue.

Trigger Point Therapy

Trigger point therapy is a bodywork technique that involves the applying of pressure to tender muscle tissue in order to relieve pain and dysfunction in other parts of the body. Trigger points are active centres of muscular hyperactivity, which often cross-over with acupuncture points. You will also find that your muscular "knots" are commonly trigger points.

Deep Transverse Frictions

Transverse friction is a transverse connective tissue therapy applied directly by the fingers. Transverse frictions use an oscillating pressure applied across the direction of the tissue fibres. This technique is used mainly on tendon or ligament injuries to help break down thickened, pain-producing scar tissue. If these lesions are not reduced then they are likely to cause further irritation, and degenerate more quickly than they should.

Compression Massage

Rhythmic compression into muscles used to create a deep hyperaemia and softening effect in the tissues. It is generally used as a warm-up for deeper, more specific massage work. Sports massage utilises compression massage.

Cross-Fibre Massage

Cross-fibre friction techniques applied in a general manner to create a stretching and broadening effect in large muscle groups; or on site-specific muscle and connective tissue, deep transverse friction applied to reduce adhesions and to help create strong, flexible repair during the healing process.

Swedish Massage

Swedish massage techniques include: long strokes, kneading, friction, tapping, percussion, vibration, effleurage, and shaking motions.
The usual sequence of techniques are: 
Effleurage: Gliding strokes with the palms, thumbs and/or fingertips
Petrissage: Kneading movements with the hands, thumbs and/or fingers
Friction: Circular pressures with the palms of hands, thumbs and/or fingers
Vibration: Oscillatory movements that shake or vibrate the body
Percussion: Brisk hacking or tapping
Passive and active movements: Bending and stretching